Coroner's Finding: Feldstein, Victoria

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign King at Adelaide in the State of South Australia, on the 28th day of February and the 22nd day of May 2024, by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Victoria Feldstein.

The said Court finds that Victoria Feldstein aged 87 years, late of Eldercare Allambi, 86 Oaklands Road, Glengowrie, South Australia died at Glengowrie, South Australia on the 23rd day of October 2020 as a result of general inanition complicating mixed vascular and Alzheimer’s dementia on a background of left fractured humerus (operated). The said Court finds that the circumstances of her death were as follows:

1. Introduction 1.1. Mrs Victoria Feldstein was born on 13 November 1932 and died on 23 October 2020 at the age of 87 years.

1.2. A Forensic Science South Australia pathology review undertaken by Dr Alexandra Yuill gave a suggested cause of death of ‘general inanition complicating mixed vascular and Alzheimer's dementia on a background of left fractured humerus (operated)’.1 I find this to have been the cause of Mrs Feldstein’s death.

2. Reason for inquest 2.1. The contribution of the fractured neck of femur to the death of Mrs Feldstein, while she was under a guardianship order with special powers pursuant to Section 32(1)(b) of the 1 Exhibit C1a

Guardianship and Administration Act 1993, meant that her death was a death in custody requiring a mandatory inquest pursuant to Section 21 of the Coroners Act 2003.

3. Background 3.1. Mrs Feldstein was born in Egypt and was of Jewish background. She met Marco Feldstein when they were both teenagers. They were married in Egypt in their early twenties and moved to Australian in 1956. They had two sons together, Jack and Roger.2

3.2. In 1978 Mrs Feldstein started a business which distributed artificial nails. She ran this business for 22 years until she and her husband retired in the late 1990s. Marco Feldstein passed away not long after retirement.

3.3. Mrs Feldstein continued to live in the family home at South Brighton.

4. Mrs Feldstein’s medical history 4.1. In 2015 Mrs Feldstein was diagnosed with dementia. In July 2016, upon referral from her general practitioner at the time, Mrs Feldstein was admitted to the Flinders Medical Centre for assessment after her son Roger Feldstein became concerned about her ability to continue to manage at home.

4.2. Jewish Care and Integrity were contacted during the admission and advised they could assist Mrs Feldstein at home while awaiting placement planning in the community.

Mrs Feldstein was subsequently discharged with a plan for Roger Feldstein to enlist the assistance of a private placement officer and await residential care.

4.3. In 2017 Roger Feldstein changed the home care support provider for Mrs Feldstein from Jewish Care and Integrity to Helping Hand Aged Care. Helping Hand assisted with preparation of all meals, showering and hygiene, cleaning and laundry and selfcare and medications, while Roger Feldstein assisted with shopping, transport and managing finances.

4.4. On 16 December 2017 Mrs Feldstein's care worker for the day finished duty and left Mrs Feldstein's home at 4pm. At 8am on 17 December 2017, a care worker arrived at Mrs Feldstein’s home and could hear Mrs Feldstein inside the premises, but she would 2 Exhibit C2

not come to the door. The care worker rang and advised her son Roger, who attended with a key and Mrs Feldstein was found lying on the hallway floor, where she had apparently fallen. It is not known how long she had been on the floor.

4.5. Mrs Feldstein was conveyed to the Flinders Medical Centre by ambulance where she was admitted and placed under a Level 1 inpatient treatment order (ITO) due to her known Alzheimer's dementia with poor insight, causing unwillingness to accept treatment and remain in hospital.

4.6. A meeting was conducted with Mrs Feldstein's family who expressed concerns for her safety at home. Mrs Feldstein was subsequently transferred to the Miles Ward at Noarlunga Hospital under continuation of the ITO for further treatment and to await plans to be made for transition into a residential aged care facility.

5. Guardianship order 5.1. On 4 January 2018 an urgent application was made by Roger Feldstein to the South Australian Civil and Administrative Tribunal (SACAT) for an interim guardianship order pursuant to section 32 of the Guardianship and Administration Act 1993. A hearing was held on 5 January 2018 and an order was granted concerning the accommodation and health care of Mrs Feldstein.

5.2. On 25 January 2018 a further SACAT hearing was held, and Roger Feldstein was appointed as his mother’s guardian with special powers of detention pursuant to section 32(1)(b). Those orders were reviewed on a number of occasions between that date and Mrs Feldstein’s death.

6. Circumstances leading to Mrs Feldstein’s death 6.1. Mrs Feldstein moved into Eldercare Allambi on 5 January 2018 and resided there until her death.

6.2. Mrs Feldstein was admitted to the aged care facility with a history of dementia with BPSD,3 hyperthyroidism, incontinence, anxiety, osteoarthritis, hypertension, GORD,4 3 Behavioural and psychological symptoms of dementia 4 Gastro-oesophageal reflux disease

reduced mobility and pain, and she had a history of falls. Mrs Feldstein was also resistive to staff assistance and would get up and walk without waiting for help.

6.3. Mrs Feldstein had no significant falls until the morning of 17 July 2020 when she had three falls within a 40-minute period. She suffered no injuries from these falls but did experience some pain afterward. An occupational therapy review was immediately conducted, and Mrs Feldstein's care plan updated in relation to her mobility needs.

6.4. On the afternoon of 15 August 2020 Mrs Feldstein was observed by staff trying to close a curtain in the hall and falling over. She suffered a small graze to her left elbow and a bruise on the left forearm.

6.5. At 8:30am on 16 August 2020 Mrs Feldstein was found by staff sitting on the floor in the passageway outside room 58, two rooms from her room. There was an 8cm skin tear on her left forearm and she was suffering severe pain in her left shoulder.

6.6. At the Flinders Medical Centre she was found to have a mid-shaft fracture to her left humerus.5 The orthopaedic team decided to manage Mrs Feldstein's injury conservatively without surgical intervention.

6.7. After discharge back to Allambi on 21 August 2020, Mrs Feldstein did not respond to conservative management and on 28 August 2020 at the Flinders Medical Centre the orthopaedic team decided that surgery was now the best option for long-term management of Mrs Feldstein's injury and pain.

6.8. Mrs Feldstein underwent open reduction internal fixation surgery on 2 September 2020 and was discharged back to Allambi on 3 September 2020.

6.9. Upon her return, Mrs Feldstein was experiencing post-surgery delirium and commenced a pain management regime which caused her to be less responsive, leading to reduced oral intake.

6.10. On the evening of 4 September 2020 she was reviewed by general practitioner, Dr Jasmin MacIntyre,6 who found her to be responsive but very confused, in extreme pain, and experiencing post-operative delirium.

5 Upper arm 6 Exhibit C3

6.11. Over the following days family members expressed concern to Allambi staff that Mrs Feldstein was sleeping most of the time and not taking much in the way of food and fluids. On 5 September 2020 a registered nurse contacted a medical practitioner who gave a telephone order to reduce her pain medication dose. Later that evening and into the following morning Mrs Feldstein became unsettled and exhibited signs of extreme pain.

6.12. Dr MacIntyre reviewed Mrs Feldstein again on 7 September 2020 and found her to be delirious and had concerns about her oral intake.

6.13. Following further review on 8 September 2020 Dr MacIntyre explained her concerns to Mrs Feldstein's family regarding her delirium, pain management and oral intake.

6.14. On 9 September 2020 there was a teleconference call including members of Mrs Feldstein’s treating medical team, her children and her grandchildren. A treatment plan was accepted by the family. Over the next two weeks the main concerns regarding Mrs Feldstein's condition were her delirium and frailty.

6.15. During the evening of 27 September 2020 Mrs Feldstein had three instances of coffee ground vomitus and was taken by ambulance to the Flinders Medical Centre, where she was found to be suffering from aspiration pneumonia and general decline in the context of poor oral intake over recent weeks since her humeral fracture surgery.

6.16. On 30 September 2020 Mrs Feldstein was discharged back to Allambi for palliative care.

6.17. Over the following weeks Mrs Feldstein's oral intake was minimal and the focus was on keeping her comfortable, settled and peaceful.

6.18. At approximately 8:10pm on 23 October 2020 Mrs Feldstein was found with no signs of life and was declared life extinct by a locum doctor at 10:45pm.

7. Conclusion and recommendations 7.1. I agree with the conclusions of the SAPOL investigating officer, Detective Brevet Sergeant Leigh Attenborough, that the guardianship order with special powers was lawful and appropriate.

7.2. In my opinion Mrs Feldstein’s care and treatment at both Eldercare Allambi and the Flinders Medical Centre was appropriate.

7.3. I make no recommendations.

Key Words: Death in Custody; Section 32 Powers; Natural Causes In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 22nd day of May, 2024.

State Coroner Inquest Number 23/2022 (2160/2020)